AANS Neurosurgeon Spotlight: September 2017 – The Enemy of Human Happiness: Pain

123AANS Neurosurgeon is the official socioeconomic publication of the American Association of Neurological Surgeons (AANS) and features information and analysis for contemporary neurosurgical practice. Topics covered relate to legislation, workforce issues and practice management as they affect the specialty of neurosurgery. The September 2017 edition of AANS Neurosurgeon explores the theme, “The Enemy of Human Happiness: Pain,” discussing the impact of pain on practice within the field for neurosurgeons, neurosurgical training and patients.

What are the ethical considerations when it comes to pain? How does this impact the education process for neurosurgeons-in-training? What impact does legislation have on patients, and how is the neurosurgeon’s responsibility defined? Without standard pain treatment practices, will future neurosurgeons be inadequately trained? These questions, along with many others, are answered throughout a number of articles in this publication.

Some highlights of the issue:

Elsewhere in the issue, readers can check out additional theme-related articles, as well as book reviews and updates from the Washington office via its “Washington Watch” column.

In addition to its regularly updated Twitter page, AANS Neurosurgeon also boasts Facebook page. Follow both social media accounts to read articles and stay current on the latest neurosurgical news.

Editor’s Note: During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

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Global Pain Initiative: Changing the Way People with Pain are Treated

winfreeChristopher J. Winfree, MD, FAANS
Department of Neurological Surgery, Columbia University
New York, NY

Pain management in American is currently undergoing a renovation. In the early 2000s, it became apparent that undertreated chronic pain was a huge health care problem. The Affordable Care Act (ACA) commissioned a detailed investigation into the status of pain health care delivery in this country. Once problems were identified by the investigation, some major initiatives were established to correct many of these issues. Neurosurgery is an important stakeholder in this process and is part of the National Pain Foundation’s (NPF) Global Pain Initiative. This effort is aimed at changing the way people with pain are treated — physically and emotionally.

In 2010, the ACA charged the National Academy of Medicine (formerly the Institute of Medicine) to publish a report entitled, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” This report detailed the relatively primitive state of pain management health care delivery in the United States. For example, chronic pain is poorly understood, pain education in physicians is poor, and the patients who have chronic pain often get suboptimal care. Rather than just highlighting the problems in pain health care delivery in America, the report specified a number of objectives to improve the state of pain health care delivery in the United States. Targeted research, funding to understand the nature of pain, providing evidence for pain treatments, identifying resources to improve physician education, health care practitioners and other stakeholders as well as patients, and the development of patient advocacy platforms were all part of their recommendations.

GPIThe NPF, led by Daniel S. Bennett, MD, is a nonprofit organization whose mission is to transform the way pain is fundamentally understood, assessed, and treated, in line with the National Academy of Medicine’s report. One important concept promoted by the NPF is that pain is actually a collection of diseases like cancer or any other major illnesses. Furthermore, the foundation believes pain is potentially curable given sufficient research and investigation in the clinical and outcome studies. The NPF’s Global Pain Initiative was set up to educate physicians, patients, government, representatives, and stakeholders through the publication of a series of peer-reviewed journal supplements on the current state of pain and treatment.

The Global Pain Initiative is currently producing a series of peer-reviewed publications evaluating the basic science of the pathophysiology of chronic pain as well as the evidence base for its non-surgical and surgical treatments. While this current state of evidence has already been published, the NPF is incorporating the perspectives of patients who suffer from chronic pain. The integration of basic scientists, clinicians, patient advocates and eventually corporate stakeholders will then allow for the most effective identification and appropriate prioritization of the remaining shortcomings in pain health care delivery. Once identified, these problems can be systematically addressed through several different mechanisms, such as:

  • Educating lawmakers to create compassionate and effective pain legislation;
  • Allocating National Institutes of Health (NIH) research funds to more completely understand pain and its treatments;
  • Initiating clinical trials to provide robust evidence for pain therapies; and
  • Developing public awareness campaigns to make sure patients and providers are aware of pain conditions and their treatments.

Neurosurgery has always played an important role in pain health care delivery which is why I currently serve as organized neurosurgery’s representative within the Global Pain Initiative. It is important for neurosurgeons to maintain an active role in this process, so we can continue to provide state-of-the-art neurosurgical pain treatments for our patients.

Editor’s Note: During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

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The Nation’s Opioid Epidemic — Continued Advocacy Needed to Turn the Tide

patGuest Post from Patrice A. Harris, MD, MA
Chair, AMA Opioid Task Force
Atlanta, GA

It is a basic tenet of physician leadership that we run toward an emergency. We evaluate the situation, make an initial diagnosis, and pursue interventions consistent with our education and training. This is as true for clinical practice as it is for policy interventions in state capitals and Capitol Hill. And it is what forms the backbone of the American Medical Association (AMA) Opioid Task Force, with the AANS and CNS playing a leading role.

Understanding that the nation’s medical societies all were undertaking parallel efforts, the AMA convened the Task Force in 2014 to coordinate and focus physician leadership on this issue. The AMA, organized neurosurgery and more than 20 other national, specialty and state societies all agree that there are six key ways in which physicians can act immediately to help reverse the epidemic:

Support physicians’ use of effective Prescription Drug Monitoring Program (PDMP). Many states have upgraded these databases to allow real-time access to current information, and permit delegated access, and some now have the capability for integration with electronic health records. Adoption of user-friendly features that can be integrated into the office workflow are among the reasons that PDMP utilization increased by 121 percent from 2014 to 2016 to more than 136 million queries.

Enhance education on effective, evidence-based prescribing and treatment. This emphasis, which began prior to recent state legislative and federal efforts to restrict opioid prescribing or mandate specific education or training, has led to:

  • More than 118,000 physicians completing courses on opioid prescribing, pain management, addiction and related areas in 2015-2016;
  • More than 12,000 additional physicians becoming certified to provide office-based medication assisted treatment for opioid use disorder;
  • From 2013-2016, opioid prescriptions decreased nationally by 14.6 percent — every state in the nation experienced a decrease; and
  • The AMA recently launched an opioid microsite that includes key resources specifically for neurosurgeons.

pa2Support access to comprehensive, affordable, compassionate treatment. Patients with a substance use disorder must have comprehensive access to treatment, including mental and behavioral health care. We support a comprehensive, interdisciplinary approach to pain management. This means insurance coverage gains must be protected, and payers and employers need to improve access to non-opioid and non-pharmacologic treatments for pain — including evidence-based surgical interventions.

“I also see a big opportunity to really re-introduce into our pain management treatment algorithm other non-opioid medications, such as anti-inflammatory agents, antidepressants and anti-epileptics,” Jennifer A. Sweet, MD, FAANS, the AANS/CNS representative to the AMA Opioid Task Force, said to the AMA last year. “There are many more drugs available than just opioids, and a multimodal approach may represent another key strategy.”

Put an end to stigma. Patients with chronic pain and patients with a substance use disorder deserve comprehensive care and compassion — not judgment.

Expand access to naloxone in the community and through co-prescribing. Due in large part to medical society advocacy, nearly every state has increased access to naloxone and expanded its use, saving tens of thousands of lives.

Encourage safe storage and disposal of prescription medication. The Task Force urges physicians to take three simple steps when prescribing medication

  1. Talk to your patients and educate them about the safe use of prescription opioids.
  2. Remind your patients that medications should be stored out of reach of children and others, and in a safe place — preferably locked.
  3. Talk to your patients about the most appropriate way to dispose of expired, unwanted and unused medications.

pa3There are signs of progress, but much more work remains — and physician leadership remains essential.

First, we need to increase access to specialists in addiction medicine and pain management. This will require policymakers and the health care community working together to increase the number of trained specialists. As provider network rules are enforced, advocates and policymakers need to consider alternative access plans that allow for timely access to care, especially in rural or isolated communities throughout the country. This is critically important as more patients now are dying from heroin and illicit fentanyl than from overdoses due to prescription opioids.

Second, we need to remove administrative barriers that stand in the way of much-needed care.  For example, health insurers should remove prior authorization requirements for medication assisted treatment (MAT) and address other similar barriers to non-opioid and non-pharmacologic pain care — including many of the options used by neurosurgeons.

Patients with opioid use disorder need access to MAT as well as alternatives for pain management. As the nation seeks to change the paradigm for treating pain and encourages physicians to recommend all appropriate pain management modalities to patients, insurance plans need to cover those treatments.

Physicians, policymakers and stakeholders should be working together to advance these solutions. Our patients are counting on us.

Editor’s Note: During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

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